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Case study 2: Improving the care of children with acute abdominal pain

For Alder Hey, a children’s hospital, acute abdominal pain comprises a major part of the workload that comes through A&E. So when they signed up with the PFCC programme, they chose to work on this care experience for children and their families.

The guiding council had strong clinical leadership, including the lead A&E consultant and consultant surgeons, with support from the transformation team. The working group included a wide range of staff, led by an A&E consultant and consultant surgeons working with staff across different teams and departments, including nursing staff, health care assistants, a play therapist, receptionists and radiology staff.

The team gathered data using shadowing, with further feedback from patients, families and also staff who had attended the unit with their own children. The team found the findings surprising: the care experience was not as smooth as they had supposed. The care pathway took longer than expected, and children spent little time in contact with health care professionals compared with the time they were waiting. The team also discovered that children were often waiting longer than they should to receive pain relief.

In addition, on closer examination it seemed that admission could be avoided for some children if assessment and investigations were organised more quickly. Staff also heard positive feedback, and were told that it was sometimes the little things that made a big difference to patients.

Consultant in Emergency Medicine, Julie Grice, said: ‘We had initial disappointment in that our system was not as smooth and proactive as we’d expected.  However, with the involvement and input from clinical and non-clinical staff and the parents and children, we altered our priorities and focus, and with relatively small changes the results were dramatic. The focus may have started with this small of group of patients, but it impacted on the culture of how we viewed all the children and families and their attendance through our emergency department. It challenged my thinking and approach and altered the way I perceive problems when they present. I believe it’s made me a better doctor.’

It emerged that the situation could be hard on the staff too. Because the care pathway was not clear, staff were dealing with anxious parents and distressed children. This sometimes led to complaints.

The team began by collecting baseline data and drew a driver diagram. They identified four main drivers of patients’ experience: dealing with pain, good communication with families so people know what is going on, getting the processes of care right (including how long people were waiting), and having good interactions with patients and families.

The responses were at multiple levels. Changes included providing pain relief more quickly. To tackle the inconsistency in the care pathway, the team developed an ‘acute abdominal pain pathway’ document and created a surgical decision unit to ensure a rapid surgical opinion. This has made a huge difference to the speed with which patients were seen. But more fundamentally, there has been a huge shift in awareness of the need to listen to patients and their families and to communicate better if they had to wait to be seen.

Consultant Paediatric and Neonatal Surgeon, Jo Minford, said: ‘It has made such a difference being able to assess children in an environment which is less stressful for them, to have all the necessary information to hand, and to have the opportunity for rapid review on the unit without the need for admission. Families find it reassuring that they are expected and excellent communication gives them confidence in our system of care. Finally, from my point of view, I can have more confidence in the standard and consistency of care provided by my junior staff.’

There has also been extremely positive feedback from families – with families reporting that their expectations have been met and pain was well managed. The team at Alder Hey have plans to carry on with this work, using the PFCC approach for other care experiences in the trust.

Case study 3: The Conversation Project